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Electromyographic Study of the Masseter Muscle after Lower Third Molar Surgery
Estudio Electromiográfico del Músculo Masetero tras Cirugía de Tercer Molar Inferior
* Tarley Eloy Pessoa de Barros; *Gabriel Denser Campolongo; Reginaldo Perilo de Oliveira; **Nilton Alves & ***Reinaldo José de Oliveira
BARROS, T. E. P.; CAMPOLONGO, G. D.; OLIVEIRA, N.; ALVES, N. & OLIVEIRA, R. J. Electromyographic study of the masseter muscle after lower third molar surgery. Int. J. Morphol., 29(1):304-309, 2011. SUMMARY: Third molar extraction surgery is one of the most frequently performed procedures in the areas of buccal-maxillofacial traumatology and surgery. The post-surgery evolution was evaluated based on the clinical evidence obtained so far. The objective of this study was to analyze the post-surgery clinical evolution of the masseter muscle by means of surface electromyography, to evaluate muscle activity. Four analyses were performed: one pre-surgery, to register the normal activity, and three in post-surgery: on the 7th, 14th and 21st postoperative days, in a sample of 30 patients. On the 21st day, there was near normal recovery of the electrical signal of the masseter in women, but in men this activity did not reach normal levels. Surface electromyography is a safe and reliable tool for postsurgery evolution control of masseter function. KEY WORDS: Electromyography; Masseter muscle; Third molar; Electrodes.
Surgical removal of the third molar (the "wisdom tooth") has become routine in dental clinics. Surgery is indicated in several situations, including orthodontic factors, poor positioning of the teeth and other factors, pericoronitis being the most frequent cause for extraction of third molar teeth. Third molars, when impacted in the bone, can cause inconvenience and are harmful to oral health, which justifies their extraction (Goldberg et al., 1985; Mercier & Precious, 1992; Cerqueira et al., 2004). However, the procedure can result in considerable pain, swelling, trismus (the most common complication), alveolitis, infection, bleeding and dentoalveolar fractures (Mercier & Precious; Chiapasco et al., 1993; Garcia-Garcia et al., 1997; Norholt et al., 1998), paralysis of the lower alveolar nerve (paresthesia), which occurs in 13.4% of cases (Brann et al., 1999) and reduced ability to open the mouth, which occurs in 31% of cases (Berge, 1996) and decreases with time (Suarez-Cunqueiro et al., 2003). Contributing factors to these sequelae include those related to the inflammatory process initiated by the
surgical procedure itself (Goldberg et al.). In the postoperative evaluation of masseter muscle function, clinical observation is predominant, but is subject to difficult and variable interpretations (Solberg, 1986). Electromyography allows muscle function to be assessed by analyzing the electrical signal produced during muscle contraction. The electrical potential of the muscles can be recorded in normal, healthy conditions or following surgical procedures, enabling damage to the muscle function, and in particular, the time required to complete function recovery (Goldstein, 2000) to be understood, interpreted, and recognized. An increased electromyographic signal is indicative of craniomandibular dysfunction, registering the hyperactivity of the masticatory muscles in the resting position and the decrease in activity during maximal voluntary contraction (Dahlström, 1989). Electromyography can also help the surgeon evaluate whether physical therapy is needed in each case, in order to accelerate a return to
Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. Unidad de Anatomía Normal, Facultad de Ciencias de la Salud, Universidad de Talca, Talca, Chile. *** Faculdade de Odontologia, UNIBAN – Universidade Bandeirante, São Paulo, Brasil.
G. The reading was performed by a physiotherapist and recorded on a specific form for the files. Faculdade de Medicina da Universidade de São Paulo. the electrodes were placed according to the following protocol: first. there was no significant difference in the side operated on (i. N. All the patients were submitted to diagnostic exams consisting of clinical.. This test therefore provides the healthcare professional with a safe and objective analysis. 29(1):304-309. fast and painless. The gain was 200 times. Porto Alegre. right and left side was operated with the same frequency in both sexes). from 20 to 25 seconds: relaxation. standard deviation. was used... with significantly higher activity among the men. Two-dimensional or bilateral tests were used to compare the data for the preoperative period (seven days before surgery.e. were recorded for each patient.. to use as a standard for the masseter). with Ag/AgCl (solid gel. Inc. in which there was voluntary relaxation of the masseter muscle. identifying the patient’s sex. applying a bandpass filter set between 20 Hz and 300 Hz to eliminate other external influences. Electromyographic study of the masseter muscle after lower third molar surgery.. through the monitoring and data logging of the masticatory muscles. Brazil. Electromiographic study: For the signal capture. from 25 to 30 seconds: contraction. The total examination time was 30 seconds. physical and radiographic evaluations. R. from 5 to 10 seconds: contraction. J. a 4channel. RESULTS General electrical activity of the masseter: The overall mean record of electrical activity among the patients before surgery on the seventh preoperative day was 73. then an earth electrode was placed on the region of the medial epicondyle of the humerus. MATERIAL AND METHOD Surface electromyography: The patient sat with the back fully supported on the chair. 7. Chi-squared. OLIVEIRA. in the Frankfort plane parallel to the ground. J. normality (Goldstein). analysis of variance (ANOVA) and the Tukey test (to distinguish differences between averages of the samples. with indication of surgical removal of the mandibular third molar. Quantitative measurements of the root mean square (RMS) of the electrical activity of the masseter muscle. referred to the Institute of Orthopedics and Traumatology of the Hospital das Clínicas. expressed in microvolts (mV). ALVES. E. CAMPOLONGO. 2011. The data were transferred to spreadsheets. Morphol. D. obtained by surface electromyography. followed by a five-second period when the patient exerted the maximum possible contraction of the masseter muscle by biting on a piece of cotton: from 0 to 5 seconds: relaxation.01. version 2. the skin was prepared with a thick sponge. Int. which undoubtedly promotes cooperation by the patient. minimum and maximum values. 305 . and the evaluation time (preoperative and days 7. divided into alternating phases of five seconds each. Electromyography is a noninvasive procedure which is easy to use. It was assumed in advance that the samples (groups) would be equivalent.0mV for both sides. 14 and 21 days after surgery: (H0 = 1 . A confidence level of 5% (= 0. Next. the paired t test (dependent samples with parametric distribution and pairs of related samples with parametric distribution). The data were interpreted using the Miography software. The statistical software GraphPad Prism (GraphPad Software.BARROS. T. Brazil) was used. from 10 to 15 seconds: relaxation. The descriptive results were expressed in means.05) was adopted. N. feet flat on the floor and arms resting on the lower limbs. 1996). 14 and 21 after surgery). Third evaluation: between the 13th and 14th postoperative days. from 15 to 20 seconds: contraction. & OLIVEIRA. and frequency (n). large array Miotool 400 surface electromyography device (Miotec. adhesive and conductor) with a distance of 20 mm between poles. In terms of gender. from Miotec. Second evaluation: between the 6th and 7th postoperative days. P. and another was fitted in the region of insertion.2 = 0). In our study 30 adult patients aged 30 years or under were evaluated. Statistical analysis: Statistical analysis was performed using the Kolmogorov-Smirnov test (for normal distribution). the student t test (independent samples with parametric distribution). a recording electrode (double) was placed on the upper portion of the masseter muscle to be studied (right or left).. Pearson's variation coefficient (for parametric distribution). Pearson's correlation test (for effectiveness of pairing between quadratic means). Fourth evaluation: between the 20th and 21st days after surgery. mean standard error. between January and December 2006. to remove fat and loose skin. the operated side. in pairs). connected to the masseter through individual double pediatric Medi-Trace electrodes. to estimate the recovery period. The results of muscle activity were analyzed and compared. The electromyographic signal was captured in four evaluations: First evaluation: between the 6th and 7th preoperative days. Electrodes: After swabbing the skin with 70% alcohol. hydrogel. 14-bit resolution. eyes open.
Analysis of variance on the operated side. Electrical activity of the masseter muscle on the operated side: On the seventh postoperative day.02) on the operated side. on the 21st day there was a recovery of electrical activity on the operated side. compared with the 7th and 14th days (p = 0. Electrical activity of the masseter among the men: Neither was there any difference between the sides among the men. on the seventh postoperative day. Recordings of electrical activity (mV) of the masseter muscle on the operated side among men. according to the preoperative evaluation and between the 7th and the 14th and 21st postoperative day. 4. OLIVEIRA. T. Electrical activity of masseter among women. 2. the record among the men fell slightly but the difference between the men and the women remained significant until the 21st postoperative day. and was significantly higher among the men.82).BARROS. It was noted that extraction of the third molar had no interference on the contralateral side in the men. Analysis of variance comparing each postoperative electromyographic evaluation in the operated side with the preoperative period shows that the activity increased significantly in the 21st day (Tukey test). Recordings of electrical activity (mV) of the masseter muscle among men. the electrical activity of the masseter muscle on the operated side fell to 66. E. according to the preoperative evaluation and between the 7th and the 14th and 21st postoperative day. a difference that was still significant on the 14th day (p = 0. with a significant difference between the sexes.. N. Fig. Analysis of variance. 1) on the 7th.22 by the paired t test). but on the seventh day. General electrical activity of the contralateral masseter: The electrical activity of the masseter on the contralateral side. N. However. but with no difference in the intervening period (Fig.02) and on the 21st day (p = 0. among the men. 2). revealing a gradual recovery of masseter activity (Fig. the comparison between the sides showed a lower electromyographic record (p = 0. Fig. according to the preoperative evaluation between the 7th and the 14th and 21st postoperative day.. fell to 69. Int.. P. Fig. Recordings of electrical activity (mV) of the masseter muscle of the operated side in women. Morphol. 29(1):304-309.1mV on average. analysis of variance revealed a difference indicating a recovery of the electrical signal on the 21st day compared to the 7th day. D. Analysis of variance (Tukey test). 3). Electromyographic study of the masseter muscle after lower third molar surgery. Recordings of electrical activity (mV) of the masseter muscle of the contralateral side between the women according to preoperative evaluation and between the 7th and the 14th and 21st postoperative days. 1. & OLIVEIRA.. J. R. ALVES. 3. CAMPOLONGO. 4). with minimal signal loss on the 7th day and a slight recovery in subsequent periods (Fig. Fig. 306 . On the contralateral side. 14th or the 21st postoperative days (p > 0. in the comparison between the seventh day after surgery and the preoperative period (p = 0. On the 14th day. on the side contralateral to the operated. showed a significant difference between the 21st day and the 7th day. 2011.00) (Fig. 1). J.Among the women. there was no significant difference between the electrical activity on operated and contralateral sides (Fig.8mV in the total sample. among the women. G.049).
thereby justifying its use as a tool for pre and postoperative assessment of muscle function (Moss & Willmont. and a battery-run computer system. contrary to our initial expectations. It is evident to the surgeon that there is some loss of quality of life among patients due to these symptoms. Correct diagnosis of muscle function abnormalities has been attempted in several ways. Mercier & Precious. T. 2002). J.. 29(1):304-309. OLIVEIRA. 1996. we also opted for surface electrodes. electromyography enabled the loss of function and recovery period to be monitored. generating more secure and reliable data and obviating the need to use several filters. since they cause difficulty performing basic mandibular movements. orthodontics and temporomandibular disorders. as was supposed based on the clinical experience. N. in order to reduce noise during acquisition (Hermens et al. demonstrating that some time is needed for normality to be restored. which with no doubt facilitated their positioning.. with a fixed distance between the poles (20mm). and can turn into serious complications such as nerve palsy (Chiapasco et al. such as the use of an isolated. extraction of third molars can result in a series of complications. it was evident that a decrease in electrical activity of the masseter occurs in the period after surgery. In our study. such as electromyography. & OLIVEIRA. ALVES. Conti et al.. Clinically. 1994. taking into account the patient’s history and the clinical examination methods used. 2000. we chose to use dual electrodes of the pediatric type. without the presence of light. The filters separate and restore the signal.. R.. 1996). These vary only in intensity. Morphol. and high-pass.). 2011. 10 to 20 Hz (Hermens et al.). Bendtsen et al. N. It is necessary to amplify the electromiographic signal. An anatomical knowledge of the region by the surgeon is also required.. we chose to use bandpass filters set between 20 Hz and 300 Hz. 1993). The masseter is the most important muscle in mandibular movements. Konrad. reducing impedance and ensuring good signal capture. Hermens et al. There is a unanimity among authors as to the most frequent of these: trismus. and the recommendations for the analog filters are low-pass. 2005). CAMPOLONGO. Digital palpation of the muscle is of great value. The purpose of these measures is to prevent direct or indirect participation of electricity. G.). Dahlström). audiometric booth. Interference can come from the electrical power supply. Robledo-Fernández.. with satisfactory results. 1993. and that recovery. 1995). DISCUSSION It is clear that even when properly indicated. Electromyographic study of the masseter muscle after lower third molar surgery. making it necessary to use filters. to determine the degree of muscular impairment (Suarez-Cunqueiro et al. Bipolar surface electrodes are preferred due to their characteristics and conditions of use. are always present after third molar tooth extractions. While other authors suggest that the reference electrode should be placed on the wrist. E. is usually attributed to muscle spasms and occurs even in more simple procedures. Garcia-Garcia et al. or inability to open the mouth. such as physiotherapy. 2004. Int. The use of electromyography to study craniomandibular disorders has been extensively discussed in the literature in specific areas. non-invasive. This impairment was found when comparing the signal before surgery with signals in the post-operative periods. does not occur between 7 and 14 days after surgery. In our work. Some symptoms. In our study. The electrodes can be inserted or placed on the surface.. The decrease in electromyographic signal observed in this study is an indirect sign of masseter impairment. which are innervated by the trigeminal nerve and are directly responsible for opening and closing the mouth. 1990. such as pain and swelling. J. and are painless.. but it is difficult to quantify the optimum pressure that needs to be exerted without using an algometer (Mohl.. Gray et al. but without interfering with its features. yet studies still show differences and doubts as to the parameters to be used as standards (Dahlström. However. 1987. swelling and pain. Robertson et al. The involvement of the muscular system can lead to a 15% to 20% decrease in mouth opening ability (Norholt et al. Muscle complications in the postoperative period after third molar extraction normally occur in the masticatory muscles. Norholt et al. and these are also known as skin electrodes. but they emphasize that sensitivity is essential. Trismus. as several measurements were taken over time.). mastication and phonation. 1984. and provide easy and quick access to the muscle (Duchêne & Goubel. They advocate the importance of developing training programs for examiners. Our results 307 . including the masseter (Stolov.BARROS. Brann et al.). D.. Norholt et al. due to impairment of the masseter and temporal muscle function (Garcia-Garcia et al. Researchers have discussed the need for palpation examinations of the masticatory muscle. Care was taken to reduce possible interference. Patient positioning and preparation for placement of the electrodes were maintained.. P.). regardless of the surgical technique used.. 500 Hz. technological development has brought other diagnostic tools. Mannion & Dolan. causing difficulty and limitation of mandibular movements (Berge. Postoperative complications are clinically and functionally characterized.
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